Tag Archives: preventive health

Incessantly the media, scientists, doctors, self-proclaimed experts of this or that pronounce they have found the answer to some burning issue. Mostly the matters involve health. What fat is best, or are carbohydrates better than saturated fats, or is fish oil really any good, or is the rampant use of statins the product of evil pharmaceutical propaganda. The list is interminable. And everyone has a voice. Actors and actresses somehow as a consequence of their on-screen fame have absorbed knowledge beyond that which is possessed by even our greatest scientists. Newscasters weigh in and authors sell their latest tomes with promises of truth. The whole dance of the experts would be quite amusing were it not so dangerous.

What seems to be missing from all those who have managed to communicate so easily with the almighty is a sense of responsibility. When people voice their opinions with such certitude, and their audience believes in their veracity with such solidarity, what is truly opinion then masquerades as fact. As a consequence, fiery battles flare among opposing sides. The vegans pound their fists shouting, “Not even a drop of oil! No fat at all!” The Wheat Belly folk eschew the grains, while the dairy exorcists discard the milk, and the Atkins aficionados chow down on meat and more meat. Get them together on TV and you have a firestorm.

Now bring in the politicians and celebrities. They take whatever “science” they find most convincing and try to turn it into law. No large sodas for the sugar busters; no trans fats for practically everyone (that one I have to admit is compelling), nothing with a face for the vegans. In short order there won’t be much left to eat at all.

I have my own take on the diet issue. In short I’m fairly certain we are all quite different, and consequently do better with different diets. As a generalization though I’d recommend moderation in all things, avoiding processed foods, eating a balanced diet, maintaining an optimal weight, and exercising daily. Perhaps that prescription would make a good law.

Fundamentally it comes down to this. We should all be permitted to eat whatever we wish as long as it doesn’t harm anyone but us. Government should not have the right to tell an individual what he or she can or cannot consume. There is a key caveat though. This holds true, “as long as it doesn’t hurt anyone else.” So what do we do about the ailments that occur as a consequence of food-induced obesity – diabetes for one? Do we penalize the consumers of sugar who as a consequence of their dietary predilections become obese and diabetic? Do they pay higher health insurance premiums? Probably not a popular notion. How about the smokers, should everyone foot the bill for his or her heart disease, COPD, and lung cancer treatments? Clearly these issues are slippery slopes, ones upon which I have no desire to tread.

I will emphasize one point however, and of this I am sure. No one knows what diet is best for all mankind. And until such a discovery is made, creating a food police force is probably not a good idea at all.

Familial Hypercholesterolemia (FH) is a genetic disorder of LDL cholesterol handling which can lead to heart attack and stroke at very young ages. You may be shocked to learn that afflicted children as young as four years old have required bypass surgery or even perished from heart attacks. More surprising still is the fact that we now recognize that FH is far more common than previously believed. Some studies indicate that one in 200 people has a “milder” form of the disease, while one in 160,000 suffers from its most severe variant. It’s all FH though, and even in mild cases the risk of heart attack can be 20 times that of a “normal” individual. Heart attacks in such cases occur much earlier in life than would ordinarily be anticipated. Here’s an example to which everyone can relate. 20% of patients who have heart attacks under the age of 45 have FH. Consider all the young people you know who’ve had heart attacks. One fifth of them probably have this genetic disorder. That is a huge number. The most recent estimate puts the number of FH patients in the US at 1 to 2 million. So that is certainly not rare! The number of extraordinarily severe cases is probably between 2 and 3 thousand, qualifying for the definition of a rare disease – being fewer than 200,000 in the US. Distressingly, only about 10% of FH patients have been identified as having the disease. That leaves 90% unrecognized, undertreated, and at great risk. We must change this pattern.

It is imperative on this Rare Disease Day that we all do our part to spread the word about FH. If you or someone you love has an LDL-C greater than 190 mg/dL you very likely bear this genetic malady. That means every one of your first-degree relatives – parents, siblings, and yes, even your children – has at least a 50% chance of also having the disease. Early treatment is key to improving outcomes. That’s why we recommend all children with a family history of premature heart disease or very high LDL cholesterol have their initial cholesterol level checked at the age of 2. By identifying family members with FH we can then treat them accordingly. Early recognition saves lives, sparing families the agony of losing a young, vibrant relative in the prime of her life. The good news is that there is much we can offer patients with FH. Novel medications and procedures such as LDL apheresis can dramatically lower LDL levels.

To learn more about such treatment strategies, please visit the FH Foundation at thefhfoundation.org. If you believe you might have FH, please join our National Registry, the CASCADE FH Registry and become one of the many people who will help us curtail the terrible toll FH often takes. We look forward to hearing from you!

Carpe Diem – Seize the Day! This powerful dictum always brings me back to Robin Williams’ moving portrayal of the beloved and inspiring professor in the film Dead Poet’s Society. It is a call to action, a renewal of the spirit and a return to optimism and determination, like the feeling of hopeful yearning we experience when we pledge those New Year’s resolutions. As the clock ticks away the final minutes of the old year, the excitement can be intoxicating. But so often we fail. After the rush of the New Year’s celebration fades and reality sets in, those ambitions can once again seem insurmountable. The truth is we very often unknowingly set ourselves up for failure.

Maybe this year we can keep a few rules in mind: Be realistic, keep it simple, and understand that self-motivation is essential when it comes to making real changes in your life. You have to be the one who is convinced you need to make a change. You have to really want it; your desire to make the change has to be greater than the desire to keep things the same. If you’ve ever spoken to someone who successfully stopped smoking or made any significant and lasting lifestyle change and asked them how they did it, the answer is always the same: “I wanted it and I just did it!”

Be realistic. Create short-term goals and make changes in small steps that are part of longer-term goals. If you need to lose twenty-five pounds, focus on losing five pounds. And instead of trying to lose five pounds in a week, focus on losing one pound a week. Acknowledge and reward your efforts and progress each step of the way, and never abandon your goals because of momentary failure or neediness. Remind yourself where you were last week or last month. If you are doing anything more than before, you have made progress. If you remain on the path you have chosen and your goals remain in view, your chance of attaining them becomes ever more likely.

Don’t get caught up in the false hope of quick fixes when it comes to making lifestyle changes. It is unfair and foolish to think that decades of unhealthful habits can be eradicated in a week or two.

Finally, don’t fall into the trap that fixing one thing you think has gone wrong is going to change your life. Getting to your ideal weight or driving a fancier car does not equal happiness. It’s not about trading places with someone else who seems to be better off than you are, or looking like the model on the cover of Vogue or GQ, and it’s not about turning back the hands of time. It’s about striving to be the best version of you at this moment and investing in your future. Health and happiness comes as a result of taking better care of you, inside and out, and requires addressing a multitude of factors every day of our lives. Don’t wait for all the stars to be in some perfect alignment; start now in the midst of everything. Today is the first day of the rest of your life.

Many of us have misgivings about the Affordable Care Act. Although voicing one’s opinion is always a good thing, in this case it should not be a distraction from that which is most important, your own personal health. So, while the politicians continue to battle this out, be sure not to neglect yourself. Instead of ruminating over who’s paying for what, be proactive and do what you can to maximize your health. Here are a few strategies to employ.

First, as hackneyed as this may sound, it is essential to eat a healthful diet and maintain (or achieve and then maintain) an optimal weight. You may believe this to be inconsequential, but having looked at patients’ blood biomarkers for many years I can unequivocally state that losing weight when necessary dramatically improves one’s signs of metabolic disease. In fact, the changes I have seen are nothing short of remarkable. Inflammatory tests, tests demonstrating oxidation of fats, and blood sugar analyses ALL improve with proper eating and appropriate weight.

Then there’s the other commonplace admonition – exercise frequently, optimally on a daily basis. As with diet and weight management, exercise is an essential element in maintaining health and combating disease. Exercise can also take one’s abnormal blood tests and convert them to normal. The good news is that exercise does not demand visits to the gym. Gardening, walking, biking, hiking, and swimming all represent excellent forms of exercise.

Perhaps most important of all is the engagement of patients and their doctors. Patients and doctors need to work in concert in order to achieve the goals we all desire. By examining novel blood tests, appropriately utilizing the best of modern medical technology, and prescribing suitable medications when necessary, your doctor can help you achieve your optimal health. After teaching you the basics of physiology your physician can show you how your body responds to healthful adjustments. You can literally see yourself get healthier over time. From personal experience treating thousands of patients I can assure you that watching your own numbers improve will be incomparably motivating. So speak to your doctor; ask for his or her help; learn as much as you can about your own body; and get healthy in 2014!

It has become common knowledge that sugar is bad for us. Interestingly, human beings require both fat and protein for optimal health and even survival, but we needn’t consume even a grain of sugar to live full and robust lives. Our love of sugar is unrequited; sugar in many ways is our enemy. It is quite probable that you’ve been to your doctor who, in reviewing blood tests, has informed you of your Hemoglobin A1c (HgA1c) level. He or she might have told you that HgA1c is a measure of your blood sugar level over the past three months. I’ve said that on many occasions to my own patients. Recently I recognized a lost opportunity in conveying the aforementioned message. Therefore, I am writing this brief note to clear the air.

Although it’s true that HgA1c tells us whether or not one’s blood sugar has been too high over the previous three months, it actually tells a far more important story. Hemoglobin (the Hg part of HgA1c) is an iron-containing protein. Proteins, and fats, are susceptible to permanent damage by high blood levels of sugar. HgA1c is actually the amount of damaged hemoglobin in our blood. It is not alone however. All proteins and fats can be victims of sugar-induced damage and the process whereby sugars permanently injure proteins and fats is termed glycation. Thus, when one has a high HgA1c he or she should understand that hemoglobin is not the only molecule in the body bearing the brunt of high sugar levels; it’s simply an easy one for us to test. Other fats and proteins such as those in our arteries, brains, nerves, kidneys, and eyes are also being marred by sugar. And when these proteins are hurt, the organs within which they reside are also damaged. Thus we experience heart disease, brain injury, peripheral neuropathies, kidney failure, and even blindness from high sugar levels.

So the message when it comes to elevated HgA1c is not simply, “you have high sugar”, it’s really, “your high sugar levels are taking a terrible toll on the many proteins and fats that support your body’s normal functioning.” So please be mindful when it comes to sugar. Sugar may be sweet, but sugar is not your friend.

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The recent conclusions of Brasky et al must be examined closely as they are not only misleading but potentially dangerous. This statement may appear extreme, but omega-3 fatty acids have been repeatedly shown to protect us against cardiovascular disease (CVD), the leading cause of death in the Western World. Therefore, if men stop eating fish and taking fish oil pills for fear of prostate cancer, they may be putting themselves at risk for CVD, a disorder that kills seven times as many men as does prostate cancer. Such a decision would be not only unwise, but potentially damaging. To better understand this, let’s examine Brasky’s findings in the context of prior data as well as our understanding of the biology of DHA and EPA.

First, many earlier trials have demonstrated a correlation between high fish consumption and low rates of prostate cancer. Some examples are: Lancet, 2001 Terry et al showed a significant correlation between high fish consumption and a low incidence of prostate cancer. The Physician’s Health Study in 2008 revealed a correlation between high fish consumption and improved survival in men with prostate cancer. A 2003 Harvard study of 48,000 men showed a higher intake of fish to be associated with a lower risk of prostate cancer. There are many other examples, but this should suffice.

Second, let’s look at plasma levels of EPA and DHA in Brasky’s trial. The reported EPA+DHA level in the plasma phospholipids was 3.62% in the non-cancer control group and 3.74% in the high-grade cancer group. This difference between controls and the worst cases is extremely small, frankly with no clinical significance. It is simply within the normal laboratory variation.

Third, is association tantamount to cause? No. Even if there were a clear association between prostate cancer and high EPA and DHA levels, that would not prove causality. Other plausible explanations exist. In fact, this would more likely be a case of reverse causation. We know that two cancer-related phenomena will increase DHA and EPA levels. First, cancerous tissues can upregulate the genes for enzymes that cause long chain fatty acids to “grow” into EPA and DHA – the desaturases and elongases. Second, we know that genetic polymorphisms in the fatty acid desaturases are associated with an increased risk of cancer. So what may be occurring here (if anything is occurring at all) is that cancer-induced changes in desaturases, or cancer-producing genetic polymorphisms in these same enzymes are causing an increase in EPA and DHA. DHA and EPA are not causing the cancers.

Fourth, we are not told the source of omega-3s in this study group. Is it mostly from fish? Some fish have very high levels of PCBs, substances known to be carcinogenic. To conclude that people should stop their fish oil supplements when some supplements are actually far “cleaner” than fish, might therefore be very misguided.

Fifth, let’s examine another population with vastly different omega-3 levels to see whether Brasky’s assertions are relatable to real life. The Japanese consume eight times as much EPA and DHA as do Americans, yet their risk of prostate cancer is about one eighth of ours. If anything, one should conclude that omega-3s are protective here.

Sixth, we can’t ignore the biology of the fatty acids. A plethora of data has demonstrated the anti-inflammatory impact of the omega-3 fatty acids EPA and DHA. Data have also uniformly shown the pro-inflammatory effects of trans-fatty acids. When trial conclusions fly in the face of our understanding of human biology (in this case, trans fats not being harmful while omega-3s causing harm) we must consider them to be highly suspect.

Finally, let’s not forget that EPA and DHA are considered by experts to be “essential” fats. In other words, we must consume them in order to live. Before we discard these indispensable fatty acids, let’s await better clinical trials, and ones that are plausible in the context of prior literature and well-documented pathophysiology.

We are barraged by data. In medicine this comes in the form of clinical trials and reviews. In everyday life data from news outlets strike us at every turn. We also have the internet and TV talk shows. Everyone seems to have an opinion about everything. So how do we separate the wheat from the chaff? When it comes to science, this is what I advise.

First, understand that science is not static; it is a process. It is also not black and white; it comes in countless shades of grey. Published studies are attempts to find biologic connections. They are single links in the chain of understanding. They do not stand alone; they always must be viewed in the context of all other clinical trials as well as our understanding of the complexity of human biology. Never though do we gain a hotline to god. Never are we able to say, “this is truth and all else fiction” after the publication of a clinical trial. So if you hear or see someone go to a place of certainty on the basis of a single trial, be very, very skeptical. Even if that individual is a so-called expert. The experts are not gods.

Second, there are levels of importance among the trials; some therefore are “better” than others. Rarely do you hear even the experts on TV speak about this. They typically speak only about the “abstract”, a brief summation at the beginning of every study. This is an area too complex for most clinicians to fully grasp. How then can we expect the lay population to comprehend this nuance?

Third, and probably most important of all, every trial comes with flaws. Sometimes these imperfections entirely devalue the trial’s results; other times they simply raise cause for concern. Regardless, to do a trial justice, one must read it with a fine tooth comb. In fact, when I really need to understand a particular study I spend four or five hours reading and critiquing it. Imagine that; four or five hours for a single trial. How then can I treat patients, teach, write, and still have time to read the many thousands of trials published annually. I can’t.

In sum, be cautious. Do not jump to conclusions when a study is published. Do not panic. Do not stop your medications or supplements until you’ve had the opportunity to discuss the findings thoroughly with your doctor. Always be circumspect and vigilant when learning about a clinical trial. Always maintain a very healthy skepticism. I guess in the final analysis the truth is that you can’t always believe what you read or hear. Competing interests often get in the way of truth. And the truth with clinical trials is that they are not at all about “the truth”. They are simply small cogs in the wheels of discovery.

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